An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology

<b>Objective</b>. The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence. <b>Methods</b>. A multidisciplinary panel was chosen based on expertise in pediatric emergency medicine, prehospital medicine, and/or evidence-based guideline development. The panel followed the National Prehospital EBG Model using the GRADE methodology to formulate questions, retrieve evidence, appraise the evidence, and formulate recommendations. The panel members initially searched the literature in 2009 and updated their searches in 2012. The panel finalized a draft of a patient care algorithm in 2012 that was presented to stakeholder organizations to gather feedback for necessary revisions. <b>Results</b>. Five strong and ten weak recommendations emerged from the process; all but one was supported by low or very low quality evidence. The panel sought to ensure that the recommendations promoted timely seizure cessation while avoiding respiratory depression and seizure recurrence. The panel recommended that all patients in an active seizure have capillary blood glucose checked and be treated with intravenous (IV) dextrose or intramuscular (IM) glucagon if &lt;60 mg/dL (3 mmol/L). The panel also recommended that non-IV routes (buccal, IM, or intranasal) of benzodiazepines (0.2 mg/kg) be used as first-line therapy for status epilepticus, rather than the rectal route. <b>Conclusions</b>. Using GRADE methodology, we have developed a pediatric seizure guideline that emphasizes the role of capillary blood glucometry and the use of buccal, IM, or intranasal benzodiazepines over IV or rectal routes. Future research is needed to compare the effectiveness and safety of these medication routes.**目标**：本指南旨在为院前儿童癫痫及时终止发作提供循证实践建议，同时避免呼吸抑制与癫痫复发。 **方法**：本指南组建了多学科专家小组，成员均具备儿科急诊医学、院前急救医学或循证指南制定领域的专业资质。小组遵循《国家院前循证指南（National Prehospital EBG）模型》，采用GRADE方法学开展问题构建、证据检索、证据评价及指南建议制定。专家小组于2009年首次开展文献检索，并于2012年更新检索范围。2012年，小组完成患者救治算法草案，并提交至利益相关方组织征求意见，以开展必要修订。 **结果**：本次指南制定过程共形成5项强推荐与10项弱推荐，除1项推荐外，其余均基于低或极低质量证据。小组致力于确保所提出的推荐能够实现癫痫及时终止，同时规避呼吸抑制与癫痫复发风险。小组建议：所有处于癫痫发作状态的患者均需检测毛细血管血糖，若血糖低于60 mg/dL（3 mmol/L），则需给予静脉注射（intravenous, IV）葡萄糖或肌内注射（intramuscular, IM）胰高血糖素治疗。此外，小组推荐将苯二氮䓬类药物的非静脉给药途径（颊黏膜给药、肌内注射或鼻内给药，剂量为0.2 mg/kg）作为癫痫持续状态（status epilepticus）的一线治疗方案，优于直肠给药途径。 **结论**：本指南采用GRADE方法学制定，针对儿科院前癫痫诊疗，强调毛细血管血糖检测的重要性，并推荐优先采用颊黏膜、肌内或鼻内给药途径的苯二氮䓬类药物，而非静脉或直肠给药途径。未来仍需开展相关研究，对比不同给药途径的疗效与安全性。